Hypervascular floor of mouth tumor: Rare presentation of oral cavity squamous cell carcinoma.

Oral squamous cell carcinoma (OSCC) is the most common malignancy affecting the oral cavity and commonly presents as an exophytic lesion with red or white granular ulcerations. Most diagnoses are confirmed by biopsy and clinical features; however, early SCC has been shown to hide within benign appearing lesions, such as vascular tumors, resulting in missed diagnoses and delay in treatment. The following case report will discuss a patient who presented with a mass in the floor of the mouth which appeared as a vascular tumor on exam and imaging. This was originally thought to be benign based on FNA findings however was found to harbor invasive squamous cell carcinoma on final pathology. The goal of this case report is to provide a background on the variable presentations of OSCC, vascular tumors, and uncommon presentations for which specialists should be aware of in their practice.

Epidermoid Cyst of the Floor of the Mouth.

ABSTRACT: Epidermoid cysts are rare, slow-growing, benign, developmental cysts that are derived from abnormally situated ectodermal tissue. Epidermoid cysts may grow anywhere on the body and about 7% of them are located in the head and neck region. They are usually asymptomatic over years but can be symptomatic due to secondary changes or the growing size. Clinically, the lesion presents as a slow-growing asymptomatic mass, usually located in the midline, above or below the mylohyoid muscle. Surgical excision from the floor of the mouth is indicated to relieve symptoms and prevent possible infection. This swelling on the floor of the mouth can sometimes cause serious problems with difficulty for swallowing and speaking. The purpose of this report is to present a case of sublingual epidermoid cyst of the floor of the mouth.

Atypical MRI and Histopathological Findings in Dermoid Cyst.

On images, a dermoid cyst is often described as resembling a "sack of marbles" or "marbles in a bag". Typically, it comprises an inhomogeneity filled with multiple nodules in a fluid matrix on both computed tomography and magnetic resonance imaging (MRI). How it appears, however, will vary depending on its histological contents, which may cause confusion in arriving at a diagnosis. This report describes a dermoid cyst in the floor of the mouth of a 55 year-old woman that showed an atypical internal appearance on MRI. Most of the lesion showed homogeneous high signal intensity on T1 - and T2-weighted images, suggesting that it was derived from fat. A small area within the mass, however, showed moderate signal intensity almost equal to that of muscle on T1-weighted images and high signal intensity on fat-suppressed T2-weighted images. Given the location of the lesion, a dermoid cyst was one possible diagnosis. A lipoma or lipoma variants were also considered, however, based on signal intensity. Histopathological section of the excised specimen revealed a dermoid cyst with sebaceous glands in its walls and keratin in its cavity. Dermoid cysts show variation in their internal structures and contents. Since MRI can reflect such histological variation, signal intensity requires careful interpretation.

Circulating microaggregates during cardiac surgery precedes postoperative stroke.

Postoperative stroke and encephalopathy are potentially serious complications associated with coronary artery bypass grafting. In this case report a 78-year-old male patient receiving routine elective cardiac surgery presented with microaggregations in the sublingual microcirculation while on cardiopulmonary bypass that was undetected by routine intraoperative anticoagulation assessment. Microaggregates identified using video microscopy on his sublingual microcirculation during the procedure preceded a stroke postoperatively. Postoperative cerebral and carotid artery examination with computed tomography scanning revealed a left watershed cerebral infarct with carotid stenosis. This report presents intraoperative microcirculation-based evidence suggesting that observations of microaggregations, otherwise undetected by conventional anticoagulation assessment techniques, could serve as an early warning in elderly patients at high risk for postoperative cerebrovascular events.

Topographical relationship between positions of lingual foramina and attachment of mylohyoid muscle in mental region.

PURPOSE: Lingual foramina can be observed between the lingual aspects of the mandible in humans. A sublingual artery is thought to exist in sublingual space and a submental artery in submaxillary space, which pierce the mandible through lingual foramina. During surgery for oral implant placement between apices of the mental foramen, it is important to determine the existence and positioning of lingual foramina. The purpose of this study was to investigate the positions of lingual foramina in relation to the mylohyoid muscle and vertical position of the mylohyoid line using cone-beam computed tomography (CBCT) images. METHODS: We examined 20 formalin-perfused cadavers. The mylohyoid muscle was dissected and marked with a silicone tube, then CBCT images were obtained to evaluate the relationship of that muscle with lingual foramina. RESULTS: We observed 37 lingual foramina in the 20 cadavers. As for vertical positioning, 16 lingual foramina were found in sublingual space, while in horizontal positioning, 6 were found in the anterior region of sublingual space. The ratio of vertical distance from the inferior margin to the mylohyoid line and mental spine was lower in the anterior region as compared to the posterior region. CONCLUSION: In this study, lingual foramina were found to commonly exist in sublingual space above the mylohyoid muscle and pierce the mesial side. For evaluation of the vertical position of the mylohyoid line, it is better to use the stable mental spine rather than the alveolar process.

Extraoral approach of the surgical treatment of sublingual epidermoid cyst: A case report.

Epidermoid and dermoid cysts account for <0.01% of all oral cavity lesions with dermoid cyst which is twice as common to epidermoid. Epidermoid cysts are benign lesions that occur rarely in children. They usually present early in life as an asymptomatic mass. The treatment option is surgical and intraoral or extraoral approaches can be performed according to the localization and size of the mass. This report presents an 11 year old child with a sublingual epidermoid cyst treated extraorally.

Venous vascular malformation of the floor of mouth masquerading as a dermoid tumor.

Venous vascular malformations (VVMs) are described as abnormal post-capillary lesions which exhibit low flow. These are typically malleable and may grow with endocrine fluctuations. A VVM that mimics the classic appearance of dermoid tumor on imaging has never been reported. We encountered a 43-year-old woman with intermittent dysphagia relating to a firm submandibular mass. Physical exam and cross-sectional imaging revealed features consistent with variant dermoid cyst. However, catheter angiography eventually demonstrated a VVM which possessed vessels of variable size and partial thrombosis. We report the case and propose that catheter angiography remains important in cases where vascular malformation is considered.

Large plunging schwannoma of the floor of the mouth involving the mylohyoid nerve: a case report and review of the literature.

Extracranial schwannomas are rare in the oral cavity, accounting for only 1% of all tumors of this type. This article presents a case study of a schwannoma arising from the mylohyoid nerve that presented as a large nodular swelling in the floor of the mouth extending into the submandibular space.

Measurement of the lingual position of the lower third molar roots using cone-beam computed tomography.

PURPOSE: The aim of this study was to evaluate the distance between the roots of the impacted third molars and the floor of the mouth to predict the risk of lingual root displacement during surgery. MATERIALS AND METHODS: Thirty-one patients (5 men and 26 women) were evaluated for this study using cone-beam computed tomography (CBCT). The teeth were grouped according to their position on the orthopantomogram as vertical, mesioangular, horizontal, and distoangular. The distance between 2 points on the roots and lingual soft tissues was measured. RESULTS: The average distance between the apex of the root, which is in the most lingual position, and the lingual cortical plate was 1.03 mm. The average distance between the most lingual point on the apical half of the root, which is in closer proximity, and the lingual cortical plate was 0.65 mm. CONCLUSION: The distance between the apices and the lingual plate is very short, which allows displacement of broken roots or teeth, especially when the lingual plate is perforated.

Sublingual ultrasound as an assessment method for predicting difficult intubation: a pilot study.

Current methods to assess the airway before tracheal intubation are variable in their ability to predict a difficult airway accurately. We hypothesised that sublingual ultrasound could provide additional information to predict a difficult airway with greater success than current methods. We recruited 110 patients to perform sublingual ultrasound on themselves following brief instruction. Ability to view the hyoid bone on sublingual ultrasound, mouth opening distance, thyromental distance, neck mobility, size of mandible and modified Mallampati classification were recorded and assessed for ability to predict a difficult intubation based on the grade of laryngoscope. Visibility of the hyoid using ultrasound was associated with a laryngoscopic grade of 1-2 (p < 0.0001), and (p < 0.0001) had a positive likelihood ratio of 21.6 and a negative likelihood ratio of 0.28. Each of the other methods had considerably lower positive likelihood ratios and lower sensitivity. Our results suggest that sublingual ultrasound is a potential tool for predicting a difficult airway in addition to conventional methods.

Pocket mobile smartphone system for the point-of-care submandibular ultrasonography.

BACKGROUND: Focused ultrasonography of the airway may be useful in the prediction of difficult intubation. The wider use of sonography in quantitative airway assessment may depend on the availability of highly portable, inexpensive, and accurate ultrasound systems. Pocket-sized ultrasound devices are emerging as a useful tool for point-of-care ultrasonography. The aim of this study was to evaluate the suprahyoid airway of healthy volunteers using a smartphone-based ultrasound imaging system in comparison with a platform-based machine. METHODS: Mobisante MobiUS SP1 system with 2 mechanical sector (3.5 and 7.5 MHz) probes was used to acquire images of the tongue and measure the diameter of the hyomental muscle in the mouth floor. In the same group of subjects, imaging and measurements were repeated using BK Medical Flex Focus 400 ultrasound system with linear (18 MHz ) and curved 5 (MHz) transducers. The MobiUS system was also used to image plastic cylinders and procedure needles embedded in tofu bars. Outside diameters of cylinders were measured using digital calipers and sonography. RESULTS: The mean diameter of the hyomental muscle in 10 healthy volunteers was 7.22 ± 1.6 mm using BK 18 MHz probe, 7.11 ± 1.7 mm using MobiUS 7.5 MHz probe, and 7.84 ± 2 mm using MobiUS 3.5 MHz probe. These means were not statistically different (BK vs Mo 7.5, P = .74, and BK vs Mo 3.5, P = .13). The mean outside diameter of plastic cylinders measured with digital calipers was 10.1 ± 0.2 mm (n = 5) vs 9.8 ± 0.3 mm and 10.2 ± 0.2 mm using 3.5 and 7.5 MHz probes, respectively. These means were not statistically different (calipers vs Mo 3.5, P = .16 and calipers vs Mo 7.5, P = .39). CONCLUSION: Mobisante MobiUS system was able to acquire clinically useful images of the suprahyoid airway and muscular architecture in the mouth floor and allowed accurate measurements of linear distances.

Management of ranula: 9 years' clinical experience in pediatric and adult patients.

PURPOSE: The aim of the present study was to evaluate the long-term results in the authors' department in the management of patients with oral and plunging ranulas. A specific diagnostic and therapeutic approach is suggested based on these data and data from the literature. MATERIALS AND METHODS: A retrospective analysis of 65 patients with a final diagnosis of ranula was carried out. The medical records were evaluated for the principal demographic, clinical, diagnostic, and therapeutic data. Statistical analysis was used to compare outcomes of the different treatments. RESULTS: Treatments that included complete sublingual gland excision were associated with the lowest recurrence rate (3.6%), followed by partial sublingual gland excision (9.1%), marsupialization (13%), and ranula excision (36.7%). Nine patients (13.8%) had recurrences. A statistically significant difference was observed (P = .01) in the recurrence rate between complete sublingual gland excision and ranula excision alone. Complications developed in 7 patients (10.8%). Ultrasonography performed in all patients showed an intimate relation among the cyst, mylohyoid muscle, and sublingual gland. Dehiscence of the mylohyoid muscle was noted in some cases. CONCLUSIONS: The surgical experience in the authors' department confirms the different treatments that are offered for ranula. Sublingual gland excision should be the preferred treatment, but marsupialization may be useful as an alternative minimally invasive procedure, with a success rate higher than 85% and no risk of increased complications if revision surgery is needed. Ultrasound is the recommended diagnostic tool, in addition to the clinical examination, for the differential diagnosis and during follow-up.

Imaging of pediatric floor of mouth lesions.

There is a vast spectrum of pathology that afflicts the floor of mouth in children. These span inflammatory conditions, vascular malformations, developmental anomalies, benign tumors and malignancies. While this area is readily evaluated on clinical exam, imaging is often performed to better characterize the disorder prior to management. The imaging modalities most frequently utilized are US, CT and MR. The purpose of this article is to describe the primary conditions that occur in this location in children so that radiologists may provide an appropriate differential diagnosis. These include ranula, venolymphatic malformation, dermoid, teratoma, foregut duplication cyst, hairy polyp, thyroglossal duct cyst and rhabdomyosarcoma. For each pathological condition, there will be a focus on describing its imaging manifestation. Floor of mouth anatomy, imaging approach during both prenatal and postnatal life and etiologies will be discussed. Surgical considerations and operative photographs will also be presented.

Imaging the floor of the mouth and the sublingual space.

A wide range of pathologic processes may involve the floor of the mouth, the part of the oral cavity that is located beneath the tongue. They include lesions that arise uniquely in this location (eg, ranula, submandibular duct obstruction) as well as various malignancies, inflammatory processes, and vascular abnormalities that may also occur elsewhere in the head and neck. Some lesions that arise in superficial tissues such as the mucosa may be easily diagnosed at physical examination. However, computed tomography, magnetic resonance imaging, or ultrasonography may be necessary for a reliable assessment of lesion extension to deeper structures. In such cases, knowledge of the complex muscular, vascular, glandular, ductal, and neural anatomy of the region is important for accurate diagnosis and treatment planning. Familiarity with the radiologic imaging appearances of the floor of the mouth and recognition of anatomic landmarks such as the mylohyoid and hyoglossus muscles are especially useful for localizing disease within this region.

Two-phase non-invasive multi-disease detection via sublingual region.

Non-invasive multi-disease detection is an active technology that detects human diseases automatically. By observing images of the human body, computers can make inferences on disease detection based on artificial intelligence and computer vision techniques. The sublingual vein, lying on the lower part of the human tongue, is a critical identifier in non-invasive multi-disease detection, reflecting health status. However, few studies have fully investigated non-invasive multi-disease detection via the sublingual vein using a quantitative method. In this paper, a two-phase sublingual-based disease detection framework for non-invasive multi-disease detection was proposed. In this framework, sublingual vein region segmentation was performed on each image in the first phase to achieve the region with the highest probability of covering the sublingual vein. In the second phase, features in this region were extracted, and multi-class classification was applied to these features to output a detection result. To better represent the characterisation of the obtained sublingual vein region, multi-feature representations were generated of the sublingual vein region (based on color, texture, shape, and latent representation). The effectiveness of sublingual-based multi-disease detection was quantitatively evaluated, and the proposed framework was based on 1103 sublingual vein images from patients in different health status categories. The best multi-feature representation was generated based on color, texture, and latent representation features with the highest accuracy of 98.05%.

Diagnosis and management of congenital floor of mouth masses: A systematic review.

OBJECTIVES: Determine the utility of preoperative imaging and the optimal course of management for congenital floor of mouth (FOM) cysts in infants. METHODS: A systematic review of the literature was performed conforming to PRISMA guidelines. Pubmed, Embase and Cochrane Library databases were queried to identify cases of infants with congenital floor of mouth masses. Patient demographics, presenting findings, imaging, management, complications, and outcomes were determined. RESULTS: 85 patients were evaluated. 98% of patients presented at 16 months of age or younger. The most common presenting symptom was submental mass or swelling, 31.3%. Among the patients that underwent imaging, the suspected diagnosis obtained from imaging findings was consistent with the final pathologic diagnosis 59% of the time reported and inaccurate 34% of the time. There were multiple definitive treatment modalities described in the literature review including surgical excision, 82.3%, marsupialization, 12.9%, chemical injection 2.3%, sclerotherapy 1.2%,% and radiation, 1.2%. Recurrence rate after initial definitive treatment was as follows, surgical excision, 8.8%, marsupialization, 80%, sclerotherapy, 100%, chemical injection, 50%, and radiation, 100%. CONCLUSION: Preoperative imaging studies should not be relied upon alone to determine suspected pathology and subsequent management in pediatric patients with FOM masses. It may be beneficial for these patients to undergo primary surgical excision regardless of imaging studies or suspected pathology. Needle aspiration offers limited addition to pathologic diagnosis and should only be performed in the setting of acute symptomatic management. Surgical excision should be considered as definitive treatment modality in all patients with FOM masses, regardless of the suspected diagnosis of ranula. Further multi-institutional cohort studies could be invaluable to elucidate definitive treatment guidelines in this patient population.

Floor of mouth schwannoma mimicking a salivary gland neoplasm: a report of the case and review of the literature.

Schwannomas or neurilemmomas are slow-growing, benign and often firm lumps that are typically painless. They are extremely rare in the oral cavity, with the tongue and the palate being the most common intraoral sites. This is a case report of this pathology in the floor of the mouth. We present a case of a 28-year-old female patient with a 2-month history of a floor of mouth swelling. On clinical examination this was non-tender and appeared firm. An ultrasound of the lesion was performed which revealed a well-defined, rounded and low reflective soft tissue mass. Following an MRI scan and surgical excision of the lesion, a definitive diagnosis of a schwannoma was made. The presence of schwannoma in the oral cavity is unusual. Based on the literature and the presented case, it should be considered as a differential diagnosis until the final histopathological confirmation.

A life-threatening floor of the mouth hematoma secondary to explantation attempt in the anterior mandible.

Implant dentistry is considered to be a safe and routine surgical procedure. However, cases of life-threatening hematoma of the floor of the mouth resulting in airway obstruction were previously reported as a complication of implant placement in the anterior mandible. Massive bleeding in this anatomical site may be caused by perforating the lingual cortex and/or damaging the lingual perimandibular vessels. In the long term, dental implants can fail, mainly due to peri-implantitis, and must be removed. Explantation procedure may occasionally become a complex challenge, with a risk for various complications.
Case report: This report presents the first case of life-threatening hematoma of the floor of the mouth, as a complication secondary to a failed attempt of dental implant removal at the anterior mandible. The proximity of the implant to the lingual vascular canal might have served as a cause for vascular damage during explantation.
Conclusions: Implant removal complications are scarcely described in the literature. Nonetheless, damaging blood vessels during explantation should not be underestimated. Computed tomography (CT) may be of value not only in preoperative implant planning but also before implant removal in jeopardized anatomical zones such as the anterior mandible. Lingual vascular canals should be looked for on computed tomography scans.